[Haemopoietic stem cells transplantation: a narrative review]

. Haemopoietic stem cells transpantation: a narrative review. Haematopoietic stem cell transplantation (HSCT) is an effective treatment for many haematological malignancies and its employment is growing thanks to the increased possibility of finding suitable donors and the discovery of therapies to treat major complications. The fourth contribution on emergencies in the oncology setting proposes a narrative literature review to describe the transplant pathway, the types of HSCT, the conditioning regimen, the stem cells reinfusion, the aplasia phase, the major complications and the follow-up. The review included secondary studies published from 2020 to 2022, on adult transplanted patients and written in English; 30 studies were included. In addition, 28 primary studies describing key issues and 11 textbooks were added. Both autologous and allogeneic HSCT expose patients to infectious or drug therapy-related complications, such as mucositis and bleedings. The allogeneic HSCT is at higher risk of major complications such as the graft-versus-host disease and the venous-occlusive disease. The update proposed is accompanied by two cases with multiple choice questions, in patients who underwent autologous stem cells hematopoietic transplantation: case 1 (published in this issue of the AIR journal) on septic shock and case 2 (which will be published in the next issue of the AIR journal) on a massive hemothorax.

[Indications for CAR-T cell therapy and management of the complications: an update]

. Indications for CAR-T cell therapy and management of the complications: an update.

INTRODUCTION

The engineering of T lymphocytes with the chimeric antigen receptor (CAR-T) opened a new pattern for the treatment of malignant neoplasms and it was pivotal for the treatment of some haematological malignancies.

AIM

To describe the therapy with CAR-T, the mechanism, the management process, the role of the multidisciplinary team and highlight the main complications and management, follow-up, the impact on quality of life and the role of nurse.

METHOD

A literature review was conducted. Secondary studies published between 1 January and 17 October 2022, in English and Italian language, on adult population undergoing CAR-T, were included. Of the 335 articles, 64 were, finally, included.

RESULTS

New CAR-T products have been tested for the treatment of acute myeloid leukaemia, multiple myeloma and some kind of solid tumours. The two main toxicities are the cytokine release syndrome and the neurotoxicity. Alternative drugs have been tested for minor adverse effects. The multidisciplinary team and the nurse are fundamental, both in the clinical care and in the organization; an emphasis was put on the correct patients' information. Quality of life after CAR-T treatment is still poorly investigated.

CONCLUSIONS

The knowledge on CAR-T is in continuous and rapid growth and several questions are still without answer, requiring a continuous update of the transplant centres.

A randomised controlled trial examining the effectiveness of cartoons as a distraction technique

AIM

Distress and pain associated with immunisation are significant problems for children, carers and healthcare professionals. This study was designed to determine whether distraction by watching cartoons during immunisation could reduce the distress and pain perceived by the children.

METHODS

A sample of 35 six year olds was randomly assigned to one of two groups: the first was distracted by standard techniques during immunisation, the second by watching cartoons. Levels of distress were measured with the amended observation scale of behavioural distress, and of pain by the Wong-Baker FACES pain rating scale.

RESULTS

The levels of distress were significantly lower in the group distracted by cartoons compared with children who received traditional distraction techniques during immunisation.

CONCLUSION

By using an easy, cheap intervention, children's first introduction to health services can be made a positive experience which will decrease the number developing pre-procedural anxiety or a fear of needles.

Unexpected deaths in medical wards during night shifts: a narrative analysis of nursing experiences

AIMS AND OBJECTIVES

To explore nurses' narratives of unexpected patient deaths during nightshifts.

BACKGROUND

Despite the importance of patient care and safety during the night, little attention has been paid to this issue in scientific literature. Very few studies have investigated the outcome of night-time nursing care in patients, and there is a distinct paucity of knowledge regarding the experiences of nurses who discover a patient who has died unexpectedly during a night shift.

DESIGN

A qualitative study design using semi-structured interviews, interpreted by a narrative inquiry methodology, was adopted.

METHODS

A purposeful sample of 15 nurses working in Italian medical wards who had found a patient who had died unexpectedly during a night shift, and who had given their informed consent were interviewed in the period from 2009-2011. An inductive content analysis of the narrated experiences was performed.

FINDINGS

A patient's unexpected death during a night shift is something that nurses fear, and when it occurs, the experience is remembered as a nightmare. From the narratives of the participant nurses, five categories described what happened at night when a patient who had died unexpectedly was discovered: (1) the night started by nurses selecting patients needing intensive surveillance; (2) patients were reprioritised for intensive surveillance; (3) nurses were deceived by apparently normal findings; (4) nurses realised the failure of their protective role; and (5) as a consequence, more intrusive surveillance measures were adopted after the event.

CONCLUSIONS

From the narratives, a number of failures in cumulative and individual surveillance occurred during the night when a patient died unexpectedly. The deaths were recognised late, causing intense pain in nurses; this experience affected the following night shifts, when the nurses' surveillance was more intensive, insistent and intrusive towards patients, even if this was unnecessary.

RELEVANCE TO CLINICAL PRACTICE

The continuing belief that the night shift is a time when fewer nurses are needed means that the number of registered nurses is reduced and reliance is placed on nursing aides instead, placing patients at risk by compromising the effectiveness of surveillance and the consequent clinical decisions made by nurses and physicians.

Mildly elevated serum creatinine concentration correlates with the extent of coronary atherosclerosis

Mildly elevated serum creatinine concentration was proposed to be a marker for increased risk of cardiovascular disease mortality. The aim of our prospective study was to evaluate a possible association between serum creatinine concentration and extent of coronary atherosclerosis together with conventional risk factors for atherosclerosis. Serum creatinine concentration was measured in 40 male patients without overt renal or ischemic renal disease (mean age 53 +/- 7 years) with stable or unstable angina undergoing routine coronary arteriography. The extent of coronary atherosclerosis was assessed by Gensini score. In univariate linear regression analysis Gensini score significantly correlated with serum concentrations of apolipoprotein AII (r=-0.3242, P<0.05) and creatinine (r=+0.3194, P<0.05), but not with serum concentrations of lipids (total, low- and high-density lipoprotein cholesterol, triglycerides), other apolipoproteins (apo B, apo AI), lipoprotein(a), autoantibodies to oxidatively modified low-density lipoprotein or age, weight and status of smoking, diabetes or hypertension. Multivariate linear regression analysis revealed that elevated serum creatinine was associated with the extent of coronary atherosclerosis independently of conventional risk factors for atherosclerosis. Mildly elevated serum creatinine was probably the marker of generalised vascular disease denoting early nephrovasculopathy in correlation with established atherosclerotic risk factors.

Comparison of laboratory parameters as risk factors for the presence and the extent of coronary or carotid atherosclerosis: the significance of apolipoprotein B to apolipoprotein all ratio

We compared several "new" risk factors (autoantibodies to oxidatively modified low density lipoprotein (LDL), sialic acid content of LDL, bilirubin and C-reactive protein) with "conventional" risk factors (apolipoprotein (apo) AI, AII and B, lipoprotein(a), triglycerides, and total, LDL and high density lipoprotein (HDL) cholesterol) for the presence and the extent of coronary or carotid atherosclerosis. Forty male patients with angiographically proven coronary atherosclerosis and 31 male patients with ultrasound-proven extracranial carotid atherosclerosis were compared to 40 age matched (53+/-5 years) healthy males as control subjects, with negative parental history of atherosclerosis, no clinical signs of systemic or organ-related ischemic disease and normal extracranial carotid arteries. The apo B/apo All ratio most powerfully indicated the presence and the extent of coronary or carotid atherosclerosis. Elevated lipoprotein(a) contributed significant additional information in the assessment of the atherosclerotic risk. Increase in C-reactive protein indicated the presence (but not the extent) of coronary or carotid atherosclerosis with a similar power as lipoprotein(a). Decreased values of total bilirubin indicated the presence of atherosclerosis only in smokers. Autoantibodies to oxidatively modified LDL additionally described the atherosclerotic process, but were less important than apolipoproteins, lipoprotein(a), C-reactive protein or bilirubin. Sialic acid content of LDL added no information to the parameters discussed above. We demonstrated that in male patients apolipoproteins, especially the apo B/apo All ratio, were better indicators of the presence and the extent of coronary or carotid atherosclerosis than C-reactive protein, bilirubin, autoantibodies to oxidatively modified LDL or sialic acid content of LDL.

The optimization of turnaround time for blood samples in an emergency clinical laboratory

The University Medical Centre Ljublijana is a 3200-bed general hospital. A laboratory information system, developed to improve the reliability and usefulness of test results, was installed in the emergency laboratory in November 1994. At that time, all test requests received by the laboratory were treated as equally urgent, but in December 1994, a reorganisation took place, which involved the introduction of a priority system. We conducted a study in the period from November 1994 to September 1995. The turnaround time for blood analyses was evaluated by the method of case study. The influence of information technology and organisational changes on individual components of the turnaround time was assessed. This study has shown a positive effect of the recently introduced information technology and organisational changes on the turnaround time. The median turnaround time improved for all phases of the laboratory process. The greatest improvement occurred in validity check time.